A randomised control trial investigating the effect of a thorough cleaning technique for shared medical equipment on the rate of healthcare associated infections

In this stepped wedge design, there are 5 clusters, with two wards making up cluster. Each step (time period) in the trial is 6 weeks. At each step, the next cluster will transition from control to intervention. Therefore, the length of the intervention will vary from 6 weeks (last cluster to transition) to 30 weeks (first cluster to transition). The intervention will consist of 1) additional cleaning and 2) education, audit and feedback on cleanliness to cleaning and nursing staff. Further detail on these two components of the intervention are provided below. This multi-modal approach is grounded in the literature and recent research. The primary target for the intervention are cleaning staff. Additional cleaning During the intervention phase, each ward will receive an additional 3 hours cleaning per weekday by dedicated (nominated) cleaners. This is in addition to routine cleaning that already occurs. The use of dedicated cleaners will reduce the risk of contamination The additional cleaning will focus on specific shared medical equipment at a minimum frequency. The use of a Therapeutic Goods Administration (TGA) registered disinfectant wipe effective against a range bacteria and viruses will be used for additional cleaning. The fidelity of the additional cleaning will be measured using the fluorescent markers, described in the next section. In addition, items that have been cleaned but remain in storage until use will be labelled as cleaned, using bright labelling. This will enable clinical staff can easily identify which equipment is clean and ready for use. Education, audit and feedback The dedicated cleaners undertaking the additional cleaning will undergo education and training prior to commencement of the intervention. Education prior to the invention will include at least a 1 hour in-service, where cleaning technique will be taught and practiced. This will occur no longer than 2 months prior to the commencement of the intervention. The training will be delivered by staff experienced in education and cleaning practice. Standard operation procedures for cleaning specific items of shared medical equipment will be developed, and subsequently explained at the in-service. These will also be readily available for staff for future reference as needed. The benefits and role of audit, including the use of fluorescent markers (FM), in assessing environmental cleaning, is well documented. Audit and feedback to the cleaning staff involved in the additional cleaning, will include the use of FM technology, in which invisible gel dots that are removed by cleaning are applied to surfaces. The dots are invisible to the naked eye, resist dry abrasion, and are removed completely by routine cleaning. A structured auditing approach, with staff feedback underpinned by education, will aid improvements in cleaning, as shown in multiple studies. During the intervention phase: • audit results will be reported to cleaning staff at the time of audit; cleaning supervisors and the nurse unit manager. • audit results will be used to inform further education and training. • additional reports will be provided for internal committees, such as the Infection Prevention and Control committee, as required. Collection process for FM audits The research team will sample up to ten pieces of shared equipment, minimum of 4 different types of equipment per ward each fortnight through the control and intervention periods. The choice of equipment will be undertaken using a random process, generated using Microsoft Excel, of nominated pieces of equipment on each ward. The person undertaking the FM audit will be a member of the research team not involved in the randomisation process and they are not part of the cleaning staff. Cleaning staff will not be aware of the exact placement of the dots. The timing of the sampling and reaudit will require some flexibility, to ensure there has been an opportunity to clean the equipment between application of the FM and subsequent review. The equipment will be checked by the research team using an ultraviolet light torch to determine whether the dot had been completely removed. The timeframe between the FM placement and checking removal will be approximately 24 hours, to allow the opportunity for the equipment to have been cleaned once.